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Nation pays high price for unnecessary tests, unproven treatments

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Cracking down on inefficient and clinically unnecessary practices like over-ordering diagnostic tests, prescribing inappropriate medications and using unproven or speculative treatments could save the health system more than $15 billion a year, a leading epidemiologist has said.

In a provocative speech to the AMA National Conference in which he called for a transformation in the way in care is conceived and delivered, Associate Professor Ian Scott said up to 30 per cent of health spending was wasteful or went on procedures and treatments that were of little benefit or could actually be harmful.

A/Professor Scott, who is director of Internal Medicine and Clinical Epidemiology at Brisbane’s Princess Alexandra Hospital, said while some interventions and treatments, like vaccination programs, public health campaigns, chemotherapy, renal dialysis and some cancer screening programs were effective uses of scarce health funds, the pay-off from many other practices was more questionable.

He questioned the bias in the medical profession to provide intensive care, including “heroic interventions”, for very ill patients – 30 per cent of health funds are spent on health care in the last year of life, including $2.4 billion on providing hospital care to the elderly – and suggested a more conservative approach involving a shift in focus away from treatments that do not improve survival beyond six months or enhance quality of life.

One of the oft-cited sources of inefficiency and cost blow-outs in the health system is in the area of diagnosis, including the tendency to over-prescribe diagnostic tests.

Much of this has been attributed to the rise of “defensive medicine”, which MDA National Manager of Medico-legal and Advisory Services, Dr Sara Bird, defined as the ordering of treatments, tests and procedures “primarily to help protect the doctor from liability”, rather than to substantially advance patient diagnosis or treatment.

Dr Bird, who addressed the same AMA National Conference policy session as A/Professor Scott, said that although the incidence of defensive medicine was difficult to measure, evidence suggested it was widespread.

In the United States, 96 per cent of specialists practising in fields at high risk of litigation confessed to practising defensively, including 43 per cent who reported ordering unnecessary diagnostic imaging tests.

Dr Bird said the situation appeared to be similar in the United Kingdom, where almost 80 per cent of hospital-based doctors said they practised defensive medicine, including 60 per cent who admitted ordering unnecessary tests and 55 per cent who said they made unnecessary referrals.

In Australia, research indicates that doctors who have been the subject of legal action are much more likely to practise defensively – 55 per cent ordered more tests and 43 per cent made more referrals than was considered usual.

A/Professor Scott said that in addition to unnecessary tests, often clinicians provided treatments that were of little or no value.

He lauded the National Prescribing Service’s Choosing Wisely initiative, under which so far more than 200 routinely used treatments have been placed under scrutiny.

The Federal Government has also commissioned a review of Medicare Benefit Schedule items, led by Sydney Medical School Dean Professor Bruce Robinson, to scrutinise and assess the appropriateness of more than 5500 listed services.

AMA President Professor Brian Owler has cautiously welcomed the reviews.

Professor Owler said that although it was important to rigorously assess the value and appropriateness of procedures and treatments, it was vital the process was not driven primarily a search for savings, and that it had the support and involvement of medical colleges and societies.

A/Professor Scott warned of “indication creep”, where a treatment proved to be of benefit to one group of patients is uncritically applied more broadly , such as cardioverter defibrillators, cardiac resynchronisation pacemakers and transcatheter aortic valves.

He urged a much more considered and cautious approach to the use of new interventions until there was rigorous evaluation of their safety and effectiveness.

A/Professor Scott said told the conference that clinical guidelines should take into account cost-effectiveness in recommending interventions.

He said often less intensive and cheaper management regimes for conditions such as bleeding peptic ulcers and urinary tract infections in children were just as safe and effective as higher-intensity regimens.

A/Professor Scott recommended that analyses of the comparative cost effectiveness be an integral part of the assessment of each new service or intervention.

He told the conference this cost-effectiveness approach should also inform the selection of patients for a particular treatment.

The epidemiologist said interventions should be targeted to those who would derive greatest benefit.

Adrian Rollins